Cardiovascular disease (CVD) is the leading cause of death in the United States. Despite strong evidence that reducing low-density lipoproteins (LDL) with statins successfully lowers CVD risk, physicians under-prescribe statins, physicians fail to intensify treatment when indicated, and more than 50% of patients stop taking statins within one year of first prescription though such therapy typically should be lifelong. In this study, we will test the effectiveness of different behavioral economic interventions in increasing statin use and reducing LDL cholesterol among patients with poor cholesterol control who are at very high risk for CVD. The application of conceptual approaches from behavioral economics offers considerable promise in advancing health and health care. Pay for performance initiatives represent one such potential application but one in which incorporating the underlying psychology of decision makers has not generally been done, and experimental tests have not been conducted. We will test these approaches among primary care physicians and their patients at very high risk of CVD at Geisinger Health System and University of Pennsylvania outpatient clinics. Using a 6-arm, cluster-randomized controlled trial, we aim to answer these questions: [1] How does the provision of provider incentives compare to the provision of patient incentives, to a combination of patient and provider incentives, or to no incentives at all? [2] Is success with provider incentives improved with enhanced information about patient adherence? [3] How does the provision of financial incentives compare to an alternative clinical approach in which lipid management defaults to a nurse practitioner rather than physician? [4] Are results sustained after incentives and other interventions are withdrawn? [5] How do these approaches compare in implementation, acceptability, cost, and cost-effectiveness? PUBLIC HEALTH RELEVANCE: Comparative effectiveness research (CER) has identified many approaches to reduce cardiovascular risk. However, the uptake of practices known to be successful is significantly lower than what is needed to optimize the health of the American population. This project proposes to test a novel strategy - financial incentives - to improve uptake of CER findings among physicians and patients to reduce cardiovascular risk.